OFFICE OF THE DIRECTOR Kate Brown, Governor October 9, 2020 500 Summer St NE E-20 Salem, OR 97301 Voice: 503-947-2340 Fax: 503-947-2341 Jim Bernard, Chair Clackamas County Board of Commissioners 2051 Kaen Road Oregon City, OR 97045 jbernard@clackamas.us Kathryn Harrington, Chair Washington County Board of Commissioners 155 North First Ave, MS-21 Hillsboro, OR 97124 kathryn_harrington@co.washington.or.us Deborah Kafoury, Chair Multnomah County Board of Commissioners 501 SE Hawthorne Blvd, Suite 600 Portland, OR 97214 chair@multco.us Dear Chairs Bernard, Harrington and Kafoury: This letter is in follow up to our meeting on August 10, 2020 and in response to your letter on August 3, 2020. We appreciate you taking time to meet with us and to share your questions and recommendations. We have outlined our responses to your recommendations and questions below. Systems Changes Hiring additional staff does allow [the counties] to expand our response, but people alone are not the sole solution we need. The following adjustments in the state’s disease response system will allow those staff to be more efficient and effective: 1. County recommendation: Change the thresholds for outbreaks to prioritize our response on the most urgent and largest outbreaks. Response: We set the reporting bar low so that public health is aware and can reach out to offer support and try to prevent outbreaks from getting larger. We open an outbreak with one case in a congregate setting as we need to prioritize actions in those settings as COVID-19 can spread easily in these facilities and more than half of fatalities have occurred in congregate living facilities. Seventy nine percent of workplace outbreaks reported prior to July 10 had 3 or more cases; reflecting that most of the outbreaks were identified early, continued to grow, and indicated a need to continue to be proactive in these settings. Tri-County Chairs October 9, 2020 Page 2 of 8 OHA engaged in a conversation with local public health administrators during a regularly scheduled call on August 28, 2020 to review workplace outbreak data and determine if any adjustments need to be made to workplace outbreak thresholds. As a result of feedback on that call, we are working with LPHA representatives and our epidemiologist team to streamline some outbreak opening and closure processes. No adjustments will be made to the congregate setting outbreak threshold. 2. County recommendation: Omit household contacts from employer outbreaks reported weekly to eliminate confusion. For example, a workplace “outbreak” may only have two employees and three household members, but the public is interpreting the case count of five as five ill employees. Response: OHA continues to receive concerns from employees worried about bringing COVID-19 home to their families. For this reason, it is important to keep household members in the workplace outbreak counts. We will continue to message the definition of workplace outbreaks to the employers we reach out to and through our media communications. This suggestion was discussed during the conversation with local public health administrators on August 28, 2020; however, given the concerns we continue to hear from employees about exposing their families to COVID-19 we do not feel a change is prudent at this time. 3. County recommendation: Create a process to report outbreaks electronically in order to streamline reporting. Response: The ability to electronically open an outbreak in Opera was built and released at the end of July. At the time, only several pilot counties have opted to have this feature “turned on;” we are once again reminding LPHAs of this feature and providing information about how to use it so more may have this capability. TriCounties were given the ability to create outbreaks on the OHA Outbreaks Database. Counties may identify up to 4 people at their level to be granted access to this system. 4. County question: Create a data dictionary for Opera, the state’s COVID-19 database, so that county staff have a clear definition of terms. This is especially important as we train new employees and expand our workforce. Response: While there is not a separate data dictionary, the information is contained in the investigative guidelines and the tool tips incorporated in Opera (see included instructions for accessing them). We are working on expanding training for Case Investigation and Contact Tracing, including additional regionalized support. As we increase staffing, the resources, support and training available to Counties will also increase. For info, ARIAS is the database for Contact Tracing, and Opera is for Case Investigation. 5. County recommendation: Develop additional training supports for case investigators and contact tracers in partnership with local public health, including Tri-County Chairs October 9, 2020 Page 3 of 8 interview training videos and a guide that addresses each data entry field for completing an interview in Opera. Response: OHA developed training and incorporated input from LPHAs. There are other trainings available from the Johns Hopkins University and Association of State and Territorial Health Officials. OHA is also training community-based organizations to conduct daily symptom monitoring for COVID-19 contacts, and many of these staff will also be supporting referral to wraparound support services for individuals in isolation or quarantine. We encourage LPHAs to incorporate training materials from various sources to best meet their unique needs. 6. County recommendation: Clarify that OHA assumes management of all complex worksites outbreaks, such as those that cross jurisdictions. Response: Our epidemiologists in health intelligence are available to manage these outbreaks. When LPHAs ask for outbreak investigation assistance OHA can take the lead in coordinating interagency support and response in close coordination with the LPHA or manage the outbreak. If the LPHA needs assistance with a complex worksite outbreak, the LPHA may contact our epidemiologists through the24/7 Epi On-Call line at 971-673-1111. 7. County recommendation: Update guidance language to ensure all businesses — not just those with public access require face coverings be worn at all times unless there is continual ability to maintain 6 feet or more of distance between employees. Response: This change to guidance was released August 13, 2020. 8. County recommendation: Employ a Personal Protective Equipment (PPE) distribution model that aligns with current epidemiological data. Multnomah County has had 23 percent of the State’s positive cases and 28 percent of the States fatalities. We believe a model using either of these percentages for future PPE distribution is more appropriate than current models. Response: In early June, OHA and DAS moved to a “pull” methodology. Counties submit PPE requests through OpsCenter which are then filled by the state. Counties are encouraged to submit their PPE needs through this process. 9. County recommendation: Expand routine, ongoing and prompt low-barrier testing access across the Tri-County region. Response: We continue to work with partners to implement community-based testing. OHA continues to support outbreak associated testing and communitybased testing when LPHA resources are limited or overwhelmed. OHA is regularly supporting events that focus on disproportionately affected communities including, but not limited to Watch List counties. 10. County recommendation: Strongly discourage documentation of negative test results for employment and out-of-state travel in order to free up testing capacity. Tri-County Chairs October 9, 2020 Page 4 of 8 Response: We have provided a letter to be given to employers to support this approach. We are working on a letter for higher education as well. We welcome the opportunity to further discuss ways to enhance the messaging. Partnership When we look at our COVID-19 statewide response, one size does not fit all. We’ve seen exceptions made to metrics or guidance for rural counties, which makes sense. We would now like to work with OHA to create an approach that makes sense for the Metro region. That includes: 1. County recommendation: Clear conversation with OHA about what existing metrics mean in the context of the Metro area, and what other metrics might better capture disease risk and response. Response: OHA began having bi-weekly meetings with the Tri-County public health administrators and health officers on September 4, 2020. Agenda items include what specifically can be done in the Tri-County area to reduce community transmission and safely return to in-person instruction in schools. An additional opportunity for this conversation is one of the regularly scheduled local public health administrator Friday calls which would enable more administrators to be involved in the discussion. If there are specific questions about existing metrics and reporting all counties are encouraged to reach out to the OHA to discuss their questions. 2. County recommendation: Allowing local health departments to confer with one another and respond as new questions are considered for addition to Opera and Orpheus. Response: We do this regularly and have made changes to the Orpheus/Opera systems based on LPHA feedback. 3. County recommendation: Discuss what different approaches might be needed for funding of Metro counties. Response: Funding for local public health authorities occurs through the Conference of Local Health Officials (CLHO). The Metro counties are encouraged to bring this conversation to that group as local public health funding discussions impact the entire public health system in Oregon. At this time, no additional federal Coronavirus Relief Funds have been allocated to Oregon. 4. County recommendation: Support local public health response by providing data to show what interventions are working. For example, are people adopting interventions such as quarantine and isolation? What barriers are employers facing in working with us? And what are the barriers at the household level? Response: Since LPHAs are working directly and in closest proximity to persons isolating/quarantining as well as workplaces experiencing outbreaks, this information is best gathered locally with best practices shared with OHA and other local public health authorities. The Coalition of Local Health Officials often has Tri-County Chairs October 9, 2020 Page 5 of 8 additional meetings for the specific purpose of sharing best practices. We continue to explore options for additional data collection for wrap-around services. Some questions could potentially be added to ARIAS for these purposes. As a part of OHA’s community-based organization work, progress reports are due in September and January and will include number of people served. OHA will be able to assess isolation and quarantine-related wraparound needs through direct cost reimbursement invoices submitted by Clackamas County and community-based organizations. Communications Disease spreads because of behavior and the environment and as a result, contact tracing alone cannot suppress cases. We need public support to modify behaviors, and employer support to modify high-risk worksites. The state can support the Tri-County region by providing financial assistance for: 1. County recommendation: Age-specific multimedia communications and partnerships with social media influencers. Response: For individuals in their 20s and 30s, the Governor’s Office has been doing online communication using Wieden+Kennedy materials. A survey aimed at this age group is being deployed to assess awareness/understanding of COVID-19, prevalence of key protective behaviors and prevalence of key risky behaviors. The survey data will inform future communication efforts. OHA will need to identify the most effective Oregon social media influencers. We welcome suggestions and further discussion on this issue. 2. County recommendation: Messaging in multiple languages through partnerships with trusted community leaders, including faith leaders and activists. Response: There has been significant work done in this area with Brink Communications, including development of the Safe + Strong campaign, which is transcreated into 11 languages. Clackamas, Multnomah and Washington counties, and OHA are working collaboratively with community-based organizations to align messaging and resources delivered by trusted community leaders. OHA also regularly translates its COVID materials into approximately ten languages. These can be used to help support community leaders in delivering health messaging and information. Translated materials are available at healthoregon.org/coronavirus. We welcome suggestions and further discussion on this issue. 3. County recommendation: Trained bi-lingual and bi-cultural multimedia creators to support the region’s public information response through its emergency operations centers. Response: Brink Communications is a woman-owned business and was named the second-most diverse privately held company in Oregon in 2019. They have 27 fulltime salaried employees, of whom 15 (55%) are people of color and four are bilingual. Approximately 80% of the work on the OHA project has been executed by BIPOC professionals employed full-time by Brink. Tri-County Chairs October 9, 2020 Page 6 of 8 Verbio, Brink’s transcreation partner, is a certified MWESB (minority-owned, women-owned, disadvantaged small business all certified through federal certification.) All of the transcreation work for the Safe + Strong campaign was done by people of color. OHA also leverages the skills of our bilingual communications staff to develop content, reach and support Latin -o/-a/-x populations. This work includes Spanish Live streaming of media availabilities and press conferences, our Spanish Facebook page and Spanish media interviews on Univision and Spanish radio stations. We welcome suggestions and further discussion on this issue. 4. County recommendation: Employer-specific messaging that motivates employers to work with public health: a. Enforcement notices sent to employers who are not cooperating with investigations Response: OHA works with OR-OSHA and other regulatory agencies for specific workplaces to assist in addressing employers that are not cooperating with investigations. LPHAs should notify OHA when these issues arise for consultation and possible engagement of other appropriate state agencies. b. Opportunities to educate businesses about the technical assistance public health will offer, including myth busting. Response: Would like to hear more about what information is needed and we can partner to amass the resources. c. Sector-specific materials and technical assistance for employers experiencing outbreaks. Response: OHA, LPHAs and other state agencies are regularly providing technical assistance to employers in certain sectors experiencing outbreaks. Several sector-specific playbooks have been developed in collaboration with other state agencies with opportunity for LPHA input to address outbreaks in certain settings. Those playbooks are posted here. We look forward to continued dialogue about what would be helpful. Currently, the public-facing playbooks cover outbreak response in Long Term Care Facilities, Developmental Disability residential settings, Food Processing Facilities and Farm/Agricultural settings. It should be noted that Playbooks offer higher level communication and coordination guidance between government agencies. They shouldn’t be considered a ‘rule’ or regulatory in an of themselves. Other barriers Financial support for investments in protective gear and community organization staffing will also support a prompt and effective response in the region. The state can provide financial assistance for: Tri-County Chairs October 9, 2020 Page 7 of 8 1. County recommendation: Hiring the financial, compliance and program staff needed to integrate the state-funded community-based organization into the local public health response. Response: Clackamas County has the funds for this included in their base program element funding. Multnomah and Washington counties may use the CARES Act funding received directly from the federal government to support this work. OHA has hired staff to support community-based organizations and has assigned a lead staff person to each local public health authority in the metro area. OHA and local public health leaders have been meeting weekly to collaboratively develop systems and mutual support for the community-based organization response work. 2. County recommendation: The purchase of adequate reusable, washable face coverings to assure that every Multnomah, Clackamas and Washington County resident has at least two face coverings. Response: OHA has provided guidance to county emergency managers for the distribution of PPE stakeholders. OpsCenter should continue to be used when Counties are not able to secure adequate supplies. 3. County recommendation: Adequate financial support for all three Counties, including Clackamas County which has struggled even more with limited CARES ACT funding. The virus does not stop at any one counties borders. These partnerships are key to battling increasing numbers of positive tests in Multnomah, Washington, and Clackamas County. Response: Clackamas County receives base and per case funding, as well as reimbursement for isolation, quarantine and wrap around services direct costs. Multnomah and Washington counties may also use the CARES Act funding received directly from the federal government to support this work. At this time, Oregon has not received adequate funding to support state and local pandemic response. Governor Brown continues to work with other elected leaders to seek adequate federal funding for state and county needs. Thank you for everything you are doing to keep everyone in your jurisdictions safe and healthy. We look forward to continuing to work together as we walk through these unprecedented times to serve all people in Oregon. Sincerely, Patrick M. Allen Director EC: Dean Sidelinger, MD, MSEd, FAAP State Health Officer and State Epidemiologist Rachael Banks, Local Public Health Administrator, Multnomah County Philip Mason-Joyner, Local Public Health Administrator, Clackamas County Tricia Mortell, Local Public Health Administrator, Washington County Tri-County Chairs October 9, 2020 Page 8 of 8 Instructions for Accessing Opera Tool Tips In Opera, there is a button on the main case screen that users can click on that opens up a new window - this new window contains the IGs, some data entry instructions, and case definitions. This is what can be used for training/orienting staff. There are tool tips throughout Opera to assist users as well. These tooltips can include definitions for terms or data entry instructions. Users simply hover over the field name to see the tool tip. The risk and follow up modules also provide date ranges for exposure and communicability. This can assist users with prompting their cases for exposures, etc during the case investigation. Opera also has conditional formatting throughout – important fields are highlighted yellow if blank. We do not have a document that defines each field in Opera, but there are many accessible tools that can assist users during their case investigation. The on-call epi and tech team are also available if any questions arise.